In the safety phase, we developed and strengthened the first level of adaptive emotional regulation skills: mindfulness and tolerance of difficult and painful feelings. With these skills in place, we are ready to move on to the next phases of the process.

Pickers and pullers tend to have specific deficits in emotional expression and assertiveness skills. Psychodynamic therapy is well-suited to developing these skills, beginning with the invitation to talk about the stressors that trigger current symptoms as well as the factors that contributed to the start of the behaviors.

One of the ways picking and pulling behaviors help people to cope is that they enable avoidance of difficult or painful emotions. In automatic pulling, this takes the form of dissociation, while in focused pulling, the focus on imperfections provides another outlet for negative feelings.

Once we can tolerate feeling our feelings, we can begin to develop ways to express them to others. This important skill can help both to process pent-up emotions from the past and to create healthier dynamics in current relationships.

My clients sometimes compare me to a massage therapist who presses on and releases trigger points of painful feelings. This comparison is apt, as I slow us down when a person’s body language doesn’t match what they are saying. Paying attention to incongruous laughter or a pasted-on smile can help us to discover anger, sadness and other painful feelings that may have felt unbearable in the past.

Referring back to the stress cup metaphor, I explain that if feelings are avoided they don’t go away. Instead they get tucked into the stress cup, adding to the cloud of yucky feelings that build up and get released through picking and pulling.

When we talk more about what initially triggered reliance each person’s reliance on picking and pulling behaviors, they have an opportunity to release feelings that may have been stored in the body for years. I ask them to tell the stories of early episodes of picking and pulling and together we try out expressing their feelings rather than suppressing them.

For example, when I find out that Paul lost his grandmother at the age of 15 and that pulling hairs from his developing beard comforted him through the loss, I have an opportunity to help him process those unresolved feelings.

Paul is able to talk about how much his grandmother meant to him and how he had tucked his sadness inside to focus on comforting his distraught mother. When he is able to cry with me, he is surprised that the feelings are bearable and the sadness comes in waves that dissipate.

Emotional expression can also help to relieve current triggers for body-focused repetitive behaviors. Four categories of stressors typically come into play: isolation or loss of a loved one, frustration, a sense of being trapped in an environment or situation, and boredom.

Discussion of the triggers in each of these categories helps us to discover the situations that overwhelm the coping mechanisms of each individual. Frustration is a common trigger for picking and pulling, and feelings of anger and dissatisfaction are often the main feelings a picker or puller is hesitant or unable to express.

One key intervention I use in my work is to encourage each person to express the frustrations that will inevitably arise in our relationship. The ability to express frustration is a key assertiveness skill, as it helps us to set boundaries that keep us safe.

For example, I engage Sara in a conversation about why she doesn’t want to talk about her feelings toward me after a scheduling snafu last month. I remark to her that she has been distant since that time and let her know that if she can express her angry feelings it could bring us closer.

When Sara tells me how my mistake hurt her, we are able to repair the rupture in our connection. She can then begin to bring this ability to manage conflict to her other relationships.

As Sara learns how to lean into the feeling cues her body gives her she can begin to assert herself more in the world.